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- 1. MACQUARIE NEUROSURGERY Evidence Based Surgery Dr Michael Mulcahy September 28th 2017
- 2. Orthosis or no orthosis for thoracolumbar fractures?
- 3. Orthosis or no orthosis for thoracolumbar fractures?
- 5. Searchable Question P - Adults with thoracolumbar A1-A4 fractures I - Orthosis C - No orthosis O - Functional outcome/disability, pain, kyphosis Q: Does management of thoracolumbar fractures with an orthosis produce superior outcomes compared to no orthosis?
- 6. Search Strategy Goal: find randomised controlled trials Informally start with Google Search medline & embase Reference check Scopus citation review Search clinical trial registries
- 7. Medline
- 9. Embase
- 11. Future trials Searched clinicaltrials.gov and anzctr.org.au: - no current relevant trials
- 13. • Inclusion: traumatic thoracolumbar #; age <80 • Exclusion: >50% loss of height; >30% reduction of the spinal canal • 133 patients • 108 AO type A1 and A2 • 25 AO type A3 • No significant difference in kyphotic measurements at 1 year • Brace had a significantly lower VAS and ODI than PoP (compression #s). No difference for burst #s Results
- 14. • Adults (age>50) with acute isolated T10-L4 AO type A3 # with no neurologic deficit • TLSO for 3 months whenever not in bed or early mobilisation • 23 patients: • 12 TLSO • 11 no brace • VAS,ODI, radiologic parameters were not significantly different at 6 month follow up Results
- 15. • 3 Canadian spine centres, 2002-2009 • A3 burst fractures; neurologically intact; age 16-60 • TLSO for 8 weeks • 96 randomised: 49 NO; 47 TLSO • no significant difference in the RMDI, VAS, radiologic measurements at 3 months Results
- 16. • 5-10 follow up of patients from one site • initially 36 enrolled (16 TLSO; 20 NO) • 23 patients available • No significant difference in RMDI, VAS, radiologic measurements Results
- 17. • single centre 2012-2013 • age >50, minor trauma neurologically intact • unclear how osteoporosis was investigated/defined • treatment for 8 weeks • 60 patients- 20 in each group (11 lost to follow-up) • ODI, VAS, radiological measurements - no significant difference in the 3 groups at 12 weeks Results
- 18. Conclusion • Bailey et al. no difference in outcome for thoracolumbar AO A3 #s at 3 month F/U • Urquhart et al. these results may be valid long-term (5-10 year follow up) • Less well conducted RCTs (Stadhouder et al.; Shamji et al.) support this. • Kim et al. did not demonstrate a difference in outcome between rigid brace, soft brace, no brace in osteoporotic anterior compression fractures • No RCTs assessing management of burst fractures in osteoporotic patients. There is a need for: • a well conducted RCT to validate the findings of Bailey’s group • an RCT of brace vs. no brace for osteoporotic thoracolumbar compression #s
Editor's Notes
- Both patients had no neurology MRI showed no involvement of posterior ligamentous complex Employ TLICS system with MRI If non-surgical, no consensus nor clinical standard for optimal treatment
- Similar injuries, but one has osteoporosis Recent JC - first long term follow up of conservative management of burst fractures age 16-60, but excluded pathologic # Osteoporotic #s are a large burden (fourth of woman >50) Brace issues: compliance; cost; prolonged admission; appplication; muscle atrophy; skin disease
- One way at emphasising why this has been an evidence sparse topic… TLICS is for determining need for surgery (0-3 non-operative; 4 equivocal; >4 operative) A3 often treated different to A4 in literature
- Should prove superiority, as I a putting the burden of proof on to the brace so to speak Didn’t want to exclude compression fractures, keep the category broad due to differing opinions on definition (see what evidence there is)
- Contentious area Relatively common Management is relatively straight forward compared to other neurosurgical issues End-game systematic review
- Used spinal injuries based on cochrane review Didn’t want to exclude surgery in case there were trials with 3 arms for example
- Use spinal fractures, a more specific subheading Use mesh term for othosis - i.e. orthotic devices (including all variations on the term)
- using emtree terms instead of mesh terms, not satisfactory
- Spine rather than vertebra Used text word rather than ti.ab. to get more results Orthotics emtree not as broad as mesh term, so use the .tw. function In retrospect…could exp spine injury
- Checked “identifier”
- “cited by” function in scopus
- 2 Dutch hospitals. Enrolment 1991 - 1997 4 Tx for compression (6 weeks physio; thermoplastic removable brace for 6 weeks; PoP cast for 6 weeks…or 12 weeks) 2 Tx for burst (thermoplastic removable brace for 12 weeks; PoP for 12 weeks) Osteoporosis not tested. Poorly designed and written/presented study.
- Pilot study at 2 hospitals in Toronto 2005-2009 Length of stay was significantly different (6 v. 3 days) Not actually a pilot study
- Pathologic #s excluded Roland Morris disability index
- Anterior column injury only Confirmed with MRI 1:1:1 randomisation Underpowered; very large confidence intervals; Short follow-up; significant loss
- Without detailed analysis, esp. risk of bias… Bailey et al. - only age 16-60. Study the elderly